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New Client Form

Thank you for giving the team at Glendale Animal Hospital the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following New Client Form before your first appointment

Name(Required)

First

Last

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Day Phone(Required)

Night Phone(Required)

Email(Required)

Pet 1

PET'S NAME

BREED

AGE / DATE OF BIRTH

COLOR / MARKINGS

SEX; SPAYED OR NEUTERED?

Are your pets vaccines current?

Yes

No

Do you have pets medical records?

Yes

No

Medical records at another veterinary Practice?

Yes

No

Name of Former Veterinary Practice

Would you like us to call you for your appointment

Yes

No

All fees are due at the time services are rendered.

Reasons or conditions that prompted your visit?

How did you become aware of our clinic?

Drove by

Yellow Pages

Was a previous client

Personal Recommendation

(whom may we thank for your referral)

If you have additional pets please fill out the following:

Pet 2

PET'S NAME

BREED

AGE / DATE OF BIRTH

COLOR / MARKINGS

SEX; SPAYED OR NEUTERED?

DOG: VACCINATION HISTORY RABIES

Pet 2

PET'S NAME

BREED

AGE / DATE OF BIRTH

COLOR / MARKINGS

SEX; SPAYED OR NEUTERED?

Please Read I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Glendale Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Glendale Animal Hospital’s collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and –

Agree

Disagree

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